Healthcare Provider Details

I. General information

NPI: 1659407260
Provider Name (Legal Business Name): ANDREW P SMITH, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 MAIN STREET SHOP CTR
WATERLOO NY
13165-1454
US

IV. Provider business mailing address

204 MAIN STREET SHOP CTR
WATERLOO NY
13165-1454
US

V. Phone/Fax

Practice location:
  • Phone: 315-539-9160
  • Fax:
Mailing address:
  • Phone: 315-539-9160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV005146-J
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberTUV005146-J
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberTUV005146-J
License Number StateNY

VIII. Authorized Official

Name: DR. ANDREW P SMITH
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 315-539-9160